Telerehabilitation for Veterans

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A pilot project is using real-time technology to access hard-to-reach patient populations

The use of real-time video technology is a growing area that can improve healthcare access for many populations.

One common access barrier is that many patients live in rural areas and must drive long distances to clinics. In larger cities, the distance to the clinic may be shorter but an increased population can make travel time longer or more challenging.

A shortage of specialty providers in physical therapy can also be addressed by virtual care. For example, due to the shortage of physical therapists in Washington State, a pilot program for the supervision of PTAs in skilled nursing facilities utilizing telerehabilitation has been implemented.1

At the Department of Veterans Affairs Central Iowa location, a pilot project is using real-time video technology to deliver physical therapy, occupational therapy and speech therapy services to rural veterans in their homes.  A visit performed in this manner mimics an in-person home visit for the veteran.

Beyond improving access for therapy services, telerehabilitation also helps patients assume a more active role in therapy. The veteran must learn how to adjust exercises with only verbal and visual instruction. The therapist is able to see what the veteran is doing and can receive feedback from the veteran on how each intervention feels.

Visiting with Veterans

To accomplish these home visits, veterans were issued a tablet device. They were not able use the tablets for personal reasons as they were unable to call out with them. The tablets we use are capable of providing vitals such as pulse oximetry, blood pressure, and heart rate with peripheral attachments. The devices can also accommodate applications as needed.

Veterans only needed to plug the device in and press a green button on the screen when the therapist called in. At the end of the therapy episode, veterans mailed back the device.

Physical therapy evaluations are performed either in the clinic, with subsequent visits conducted in the home, or performed with a technician present to deliver the tablet and ensure safety as needed.

Equipment was similar to that used for a standard home evaluation. Goniometry could be completed by having the technician place stickers on bony landmarks and holding the goniometer up to the screen. Specific manual muscle testing was not feasible except for plantarflexors.

Special tests included those that did not require the therapist to place their hands on the patient. For instance, the Tinetti test would not work due to the need for a perturbation, but the Berg test could be used along with paper-and-pencil tests.

Treatments were performed by providing the veteran with an initial home program packet after the evaluation. As the home program progressed, some exercises were crossed out and new ones were mailed. The veteran was also issued equipment to supplement the home exercise program as needed, such as elastic bands, restorators, assistive devices for gait, modalities such as TENS, and items for manual techniques such as trigger point release.

Drawbacks and Advantages

Some of the barriers to using telerehabilitation include appropriateness of the patient and technical issues such as connectivity. Not all patients were appropriate for therapy delivered this way. Appropriateness criteria for veterans to be consulted via video include sufficient cognition to use a device and follow instruction, adequate hearing and vision to communicate with the therapist, and being medically stable.2

Despite these barriers, there were many positive outcomes. Many veterans liked the convenience. Data from a fiscal-year 2014 bill for telehealth indicated a 92% satisfaction rate. Furthermore, data from the pilot project showed telehealth visits saved an average of 57 miles per visit. Telerehabilitation also assisted in reducing hospital re-admissions.

Some areas in which to advance telerehabilitation include the use of peripherals and the increased use of applications. Peripherals could include hand-held manual muscle testers that send data to the device and body-worn motion detectors.

The creation of applications is another area that can advance this method for delivering therapy. Applications can be used for improved patient education regarding disease processes, exercise technique, and tracking of home exercise programs to improve compliance.

Video demonstrations of exercises could also improve outcomes. Specific programs can be developed, such as chronic pain and women’s health.

Telerehabilitation is a growing area in physical therapy. A recent systematic review revealed that real-time telerehabilitation can be superior to standard care for a variety of musculoskeletal conditions.3 Real-time video technology can reduce barriers to physical therapy services for many patients and help facilitate a more active patient role in their rehabilitation.


References

  1. Lee AC, Billings M. Telehealth implementation in a skilled nursing facility: Case report for physical therapist practice in Washington. Phys Ther. 2016;96(2):252-259.
  2. Clark PG, Dawson SJ, Scheideman-Miller C, Post ML. TeleRehab: Stroke teletherapy and management using two-way interactive video. Neurology Report. 2002;26(2):87-93.
  3. Cottrell MA, Galea OA, O’Leary SP, et al. Real-time telerehabilitation for the treatment of musculoskeletal conditions is effective and comparable to standard practice: A systematic review and meta-anaylsis. Clin Rehabil. 2016;(May 2):doi:10.1177/0269215516645148.
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About Author

Donald Hayes, PT

Donald Hayes is a physical therapist for the Central Iowa VA Health Care System. Contact: donald.hayes2@va.gov

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